- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.31 / $2,136.37 / $2,204.78
| Facility | | $1,444.31 | $2,136.37 | $2,204.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.31 / $1,654.93 / $3,008.97
| Professional | | $1,444.31 | $1,654.93 | $3,008.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,161.29 / $3,319.35 / $14,592.51
| Facility | | $3,161.29 | $3,319.35 | $14,592.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,673.02 / $1,696.36 / $2,557.62
| Professional | | $1,673.02 | $1,696.36 | $2,557.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $1,743.07
| Facility | | $1,743.07 | $1,743.07 | $1,743.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $1,272.44
| Professional | | $1,272.44 | $1,272.44 | $1,272.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.31 / $2,547.75 / $14,630.94
| Facility | | $1,444.31 | $2,547.75 | $14,630.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.73 / $1,689.84 / $2,909.63
| Professional | | $1,159.73 | $1,689.84 | $2,909.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.73 / $1,577.14 / $2,203.48
| Professional | | $1,159.73 | $1,577.14 | $2,203.48 |